ABSTRACTIntroduction- Missed healthcare appointments are costly and only partially remedied by reminders. Improved understanding of how dental patients’ cognitions and feelings influence attendance should help to identify behavioral management techniques to improve dental attendance and, with that, oral health outcomes. Objectives- To test a hypothetical model suggesting that patients pass through a ‘psychological cycle’ when undergoing a course of dental care: past appointment experiences influence their anticipations for future dental visits, which in turn affect behavioral intentions to attend appointments. Methods- Self-administered questionnaires were given to 300 students from 5 different colleges in Bangalore city. The questionnaire assessed variables representing the various stages of the hypothesized model and other relevant variables (dental anxiety, general anxiety and subjective oral health rating) Results- Sequential regression analysis showed that cognitive factors like negative past experiences (p=0.04) and, expectations and anticipation of future dental appointments (p<0.001) along with psychological factors like dental anxiety (p=0.05) and general anxiety (p=0.02) influenced behavioural intentions to attend future appointments. These findings were consistent with the hypothetical model. Conclusion- The model explains dental appointment attendance behavior based on the contributions of cognitive factors such as expectation and anticipation of future appointments along with past dental experience and can be used to foster better utilization of dental care. INTRODUCTIONDental appointment attendance is associated with better oral health, lower plaque and calculus levels, and better individual oral self-care, such as tooth brushing and use of additional dental hygiene products.1 Missed healthcare appointments are costly and only partially remedied by reminders.2 They contribute to adverse oral healthcare outcomes. They interrupt continuity of care, waste resources, interrupt workflow, and reduce population-wide access to care by artificially reducing the number of available appointments. Moreover, they are a facet of dental care under-utilization.3In dentistry, it is already known that socioeconomic factors play a role in the appointment keeping behavior of the patient.4,5 But despite compelling evidence, less is known about psychological factors, and their contribution to oral health-related behaviors.6 Although many oral health related quality of life studies are considering physical, mental, and social aspects of oral health care, the research on psychological factors in dentistry is still scant. Improved understanding of how dental patients’ cognitions and feelings influence attendance should help to identify behavioral management techniques to improve dental attendance and, with that, oral health outcomes.7There are a wide range of psychological models and theories which provide an important framework for increasing our understanding of the determinants of health behaviours.5 Clearly defined multistage cycle models are a step in the right direction, accounting for the dynamic nature of recurring engagement with dental care providers. Such models have had some success in explaining patterns of attendance behaviors, in samples of people with dental anxiety but neglect cognitive factors.7The Dynamic Well-being Model offers a holistic approach to wellbeing, defining links between peoples’ experiences, recollections, anticipations, intentions, and behaviors. It therefore provides a good starting point for modeling how psychological appraisals of one event can influence feelings and behaviors relating to a later one.7 The psychological cycle proposed by Schneider A et al (2016), gives a good overview of the stages that the patients go through at different points of time relative to their dental appointments. The cycle explains the inter-relationship of appointment keeping behaviour of patients with their past experience at the dental office and the anticipation they have for the future appointments. Appointment outcomes (for example, type of treatment) and experiences are closely related to time. Planning an appointment (for example, booking it) is regarded as specific behavior and evaluations feed directly into future anticipations (for example, expecting treatment or feeling anxious).7 In 18-25 year old patients, these stages may be influenced by a variety of factors like lack of time, high cost, fear of dental treatment etc which can lead to missed dental appointment. Thus, this study aimed to assess the dental appointment attendance by using the psychological cycle7 that includes experiences, anticipations and behaviours in 18-25 year olds.MATERIALS & METHODSThis analytical cross-sectional study was conducted on 18-25year old students attending 5 colleges in Bangalore City. The sample size was obtained by using nomogram with 90% power and 35% standard difference. The sample size obtained using this method was 300.8 The required sample was recruited using a convenience sampling technique. The study received formal review and approval by the institutional review board of the KLE Institute of Dental sciences, Bangalore. The study was conducted between July-August 2016. Data was collected using a self-administered questionnaire.7 Informed consent was taken from the participants before administration of the questionnaire. Only those participants who gave informed consent and who had visited a dentist in the past were included in the study. The response rate for the study was 100%. The questionnaire administered collected basic demographic data and used the psychological model given by Schneider A et al7 (Fig 1). This model assessed 3 principal domains- Experience, Anticipation and Behaviour. It assessed how the past experiences determine what the patients anticipate from the future dental visits and thus explaining the behavioural intentions of the patients to attend future dental appointments. Figure 1- Model of the Psychological Dental CycleFor assessment of the Experience domain, the participants were asked about the type of appointment (check-up, filling/root-canal, scaling, orthodontic treatment, extraction and prosthetic rehabilitation of teeth). Participants were asked to rate how uneasy and painful the appointment was on a 10-point likert scale (0- not at all, and 10- extreme).For assessment of the Anticipation domain, the participants evaluated their most recent dental visit with numerical ratings of six satisfaction statements adapted from the SERVQUAL9 questionnaire, a scale measuring consumer perception of service quality. Rating scales ranged from zero (‘strong disagreement’) to 10 (‘strong agreement’) assessing issues such as satisfaction, reliability, responsiveness, assurance, and empathy of the dentist and dental team.7To assess the Behavioural domain, the participants were asked if they have any plans to visit their dentist in the future, and how likely they were to postpone the appointment (0-not at all likely, 10-extremely likely). These questions gave the behavioural intentions of the participants towards dental appointment.In addition to these, the participants answered a single question on their oral health which they rated as 0- worst imaginable to 10- best imaginable. They also answered the Modified Dental Anxiety Scale (MDAS)10,11 which is currently the most widely used scale for assessment of dental anxiety. It was proposed by Humphris et al in 1995. It is a 5-item scale that covers questions on anxiety about the next dental appointment, anxiety in the waiting room, during drilling a tooth, during scaling and polishing and during anesthetic injections. The responses are measured on a 5-point likert scale (1-not anxious, 2- slightly anxious, 3-fairly anxious, 4- very anxious and 5- extremely anxious). The 21-item Depression-Anxiety-Stress Scale (DASS)12 assessed the general well being of the participants. This short, validated version of the DASS assesses symptoms of general anxiety, depression, and stress on a scale from zero (‘did not apply to me at all’) to three (‘applied to me very much’)7Statistical Analysis-Data was analysed using SPSS v.20. Descriptive statistics were computed first to summarize characteristics of the study population. Sequential logistic regression was employed to assess the appointment keeping behaviour. The stepwise approach allows for testing the hypothesized mediation effects with the cross-sectional data at hand, entering predictor variables into the regression model one at a time.7,13 The outcome variable was “behavioural intention for future dental appointment. P-value was set at <0.05 for statistically significant results.RESULTSA total of 300 students participated in the study. The response rate was 100%. Out of these, 225 (75%) were between 18-20 year old age group and 75 (25%) fell between 21-25 year old age group. The mean age of the participants was 19.67 (SD=1.59). The sample consisted of 177 (59%) females and 123 (41%) males. The sample was diverse and had students belonging to 5 different faculties- B.com, Pharmacy, B.Sc, Management and Law. 129 (43%) participants reported that the last time they visited a dentist was more than a year ago and only 87 (29%) participants said their last visit was less than 6months ago. 68 (22.7%) said that they postponed their previous dental appointment and out of these, 40 (58.82%) said that they postponed it due to fear (Table 1).Sequential logistic regression was used to assess the influence of all variables on “behavioural intention” which was the outcome variable (Table 2). In the first stage, the MDAS, DASS and the self rated oral health scores were added to the regression model to check for influences of these factors on the behavioural intentions. Only dental anxiety showed a significant influence on the behavioural intentions of the participants. Participants with high dental anxiety (MDAS) had 1.81 times higher chance of missing their future dental appointments than those with low dental anxiety.In the second step, the variables in the experience stage were added. In this, both dental anxiety and negative past experience significantly influenced the behavioural intentions. Participants with a negative past dental experience had 1.51 times higher odds of missing their future dental appointments than those without negative experience in the past.In the third step, the anticipation stage was added. Among the variables in the SERVQUAL, “attention from the dental team” and “trust towards the dental team” showed statistically significant results. Lower the trust in the dental team, higher are the chances of missing future dental appointments. Expectation of uneasiness and pain also had higher chances of missing future dental appointments, which was statistically significant.DISCUSSIONMissed appointments and no shows, or treatment discontinuation are adverse clinical outcomes at many healthcare facilities, and cause to affect patients health or to increase risk factors of recurrence of the symptoms. Especially in dentistry, treatment discontinuation would largely determine the clinical outcome and its prognosis. This is because, in many cases, patients need to receive regular dental treatment for a relevantly long period of time.14This study tested the model of psychological dental cycle proposed by Schneider A et al (2016)7, and assessed the various influences on dental appointment keeping behaviours. This study demonstrated that dental anxiety was a predictor of appointment keeping behaviours alone and in conjunction with negative dental experiences in the past (experience). The evaluation of past dental experience and the expectation of pain and uneasiness in the future dental appointment (anticipation), significantly influenced the behavioural intentions of future dental appointments.These findings are supported by previous study conducted by Schneider A et al (2016)7, which showed that dental anxiety is not the sole predictor of dental attendance and explains patients’ experiences and behaviours at different stages of their dental appointment. This study stresses the importance of psychological factors in dentistry.15-17 In line with theoretical predictions based on the dynamic wellbeing model (DWM), results are consistent with dental experiences following a characteristic cycle of sequential stages that integrates behavioral, cognitive, and emotional aspects.7,18Dental anxiety was shown to be a significant predictor of dental appointment behaviour. This finding is supported by the studies conducted by Berggren U et al (1984)19 and Armfield et al (2007, 2013)20-21. Negative past dental experiences was associated with missed appointments in studies conducted by Berggren U et al (1984)19 and Berge et al (2016)22. Similar results were found in the present study which indicates that a pleasant dental experience can foster more co-operative patients. Deyo R.A et al (1980)23 suggested that the relationship between the patient and the therapist greatly influences the appointment keeping behaviour which is supported by this study where we found significant influence of evaluation of previous appointments on the behavioural intentions towards future appointments, which means that if the past dental appointments are unsatisfactory, the chances that the patient will miss the next appointments are high. In contrast, a study conducted by Gunter-Hunt G (1982)24 suggested that the level of patient satisfaction influences the appointment keeping behaviours of the patients, although they did not find any correlation between the two.Despite the substantial support of the literature, the study has limitations. Because of the cross-sectional nature of the study, only the intentions of appointment keeping behaviours could be assessed i.e, this study could not assess the actual behaviours of the participants. The present sample of participants is not representative because a convenience method of sampling was employed, which provides only partial generalizability. Memory bias could have affected the data on previous dental experiences. Longitudinal studies are recommended to establish causal replationships between the factors considered in the study and the appointment keeping behaviours.CONCLUSIONThis study successfully tests the model of psychological dental cycle which explains that negative past experiences lead to negative evaluations of previous dental visits which affects the anticipation of future appointments and thus influences the intention to attend future dental appointments.